GOOD SLEEP, INC



Welcome toNations Sleep Disorders Center of Middle Georgia LLC.

We would like to thank you for choosing us as your sleep health care provider.

Your health is a responsibility we take very seriously. Nations Sleep Disorders Center of Middle Georgia LLC..specializes in providing diagnosis, treatment, and medical management for individuals with sleep / wake disorders such as sleep apnea, insomnia, narcolepsy, and others. We have offices located throughout the South East and Low Country to conveniently serve you.

Enclosed are several forms and questionnaires. It is important that you complete each of these and bring them to your first appointment or you may upload them back to us through our (Contact us by web page and upload it straight to our office). These forms are required to be filled out at time of arrival. These forms and questions are often required by Insurance Providers for their Medical Necessity.

Please bring the following with you when you come for your appointment:

• Your current health insurance card(s)

• Your valid driver’s license or other state issued photo identification

• Utility bill or other correspondence showing your current residential address if your photo ID does not show your current address

Each line must be initialed where needed and signed where needed. We will not provide service if these are not done before time of service

If you are unable to keep your appointment, please call and let us know. We will be happy to re-schedule you for a more convenient time. If you do not keep your appointment and do not call to re-schedule or cancel at least 72 hours prior to your scheduled appointment, a charge will be billed to you.

Warner Robins- 524 S Houston Lake Rd Suite E200,

Warner Robins, GA 31088

(478) 953.0262 Fax (478)953.0263

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All paper work must be turned in to our office 72 hours prior to your appointment. If it is not turned in to our office your appointment will be canceled and you will be charged a reschedule fee.

Please Contact our office during business hours for directions to our offices. Our telephones are not answered after hours.

Our Business office hours are Monday thru Wednesday 9am to 5pm

Thursday 9am to 12pm and Closed Fridays

We are closed Saturday and Sunday

Night time Technicians do not answer the phones after hours, so that time is not taken away from the patients.

TODAY’S DATE: ____________________

|Name |SS # |Driver’s License # |

|Date of Birth |Age |E-mail Address |

|Address |

|City |State |Zip Code |

|Home Phone |Cell Phone |Business Phone |

|Marital Status |( Single |( Married |( Divorced |( Widowed |

|Employer |

|Position/Job Title |

|Name of Spouse |Date of Birth |

|Employed By |SS # |

|Referring Physician |Primary Care Physician |

|Insurance Company |Policy # |

|Medicare # |Medicaid # |

|Secondary Insurance Company |Policy # |

|Third Policy. Insurance Company |Policy # |

Person responsible for this account:

|Name |Address |Relationship to Patient |

Name, address, and phone of nearest relative not living at your address:

|Name |Address |Phone |

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|Nations Sleep Disorders Center | |

|of Middle Georgia LLC. | |

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I authorize Nations Sleep Disorders Center of Middle Georgia LLC..(Nations SDC) to release to my insurance company any information required for services provided. I also assign any insurance benefits to Nations Sleep Disorders Center of Middle Georgia LLC..(Nations SDC) for any and all charges met by the insurance company.

I understand that I remain responsible to Nations Sleep Disorders Center of Middle Georgia LLC.. for any and all charges not met by the insurance company.

I, the undersigned, hereby agree that in the event of default in the payment of any amount due, and if this account is placed in the hands of an agency or attorney for collection or legal action, to pay an additional charge equal to the cost of the collection including agency and attorney fees and court costs incurred and permitted by laws governing these transactions.

I understand that if my office visit requires that I be seen by the nurse practitioner and/or the respiratory therapist that I will be billed for those services accordingly. I understand that I may be billed a separate fee from the facility for seeing the Physician or Nurse Practitioner.

Signature: ___________________________________________________ Date: _______________________

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply.

I authorize any holder of medical information about me to release such information to Nations Sleep Disorders Center of Middle Georgia LLC.. as it applies to my care and treatment rendered by Nations Sleep Disorders Center of Middle Georgia LLC..

Signature: ___________________________________________________ Date: _______________________

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|Nations Sleep Disorders Center | |

|of Middle Georgia LLC. | |

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SLEEP HEALTH QUESTIONNAIRE

NAME: ___________________________________________________ AGE: _________ DOB: ____________________

Height: ________ Weight:________Neck Size:__________BMI (Body Mass Index):___________

|Describe your main problem(s), in your own words, including when this began: |

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How often does this problem occur? ( Almost every night ( 3-5 nights a week ( 1-2 nights a week ( Other _______

How long has this problem bothered you? ( Longer than 2 years ( 1-2 years ( Less than 1 year ( 1-3 months

Describe your sleep problem (check all of the following that apply):

( Difficulty falling asleep ( Waking up during the night ( Waking up early in morning ( Difficulty waking up

( Excessive daytime sleepiness ( Fallen asleep while driving

Please list any treatments you have received for your sleep problem(s).

______________________________________________________________________________________________________________________________________________________________________________________________________________________

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MAIN CONCERN

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|Have you ever been told you stop breathing in your sleep?___________________________ Have you ever had a mental evaluation?______________ |

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|Do you require a care taker at night?_______________________________ Do you suffer from PTSD?______________________________ |

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|Do you sleep on Oxygen?____________________________ Do you take a sleep aid to help you sleep at night?__________________ |

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|Are you OCD?___________ Are you ADD?___________ Are you ADHD?___________ Are you ODD? _____________ |

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|Do you take antidepressants/SSRI currently? ( this can alter EEG on Sleep study so we must know) _____________ If yes what _________________ |

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|Do you currently take pain medications? __________________ if yes what __________________________________________________ |

|WHAT IS YOUR USUAL BED TIME? |HOW LONG DOES IT TAKE YOU TO FALL ASLEEP? |

|HOW LONG DO YOU SLEEP? |HOW MANY TIMES DO YOU WAKE UP AT NIGHT? |

|WHAT TIME DO YOU WAKE UP? |WHAT TIME DO YOU GET OUT OF BED? |

SLEEP FEATURES

| | |

|DO YOU SNORE? ____ YES ____ NO |DO YOU KICK YOUR LEGS DURING SLEEP? ____ YES ____ NO |

|DO YOU TALK, WALK, | |

|OR EAT DURING SLEEP? ____ YES ____ NO |DO YOU DREAM? ____ YES ____ NO |

|DOES YOUR SLEEP PARTNER | |

|OBSERVE ANY SLEEP ABNORMALITIES? ____ YES ____ NO |DO YOU ACT OUT YOUR DREAMS? ____ YES ____ NO |

|DO YOU HAVE ANY DAYTIME | |

|SLEEPINESS? ____ YES ____ NO |DO YOU WORK SHIFT WORK? ____ YES ____ NO |

|HAVE YOU EVER HAD |IF YES WHAT SHIFTS? |

|A SLEEP STUDY? ____ YES ____ NO | |

|IF YES WHAT DATE_______________ | |

|WHERE AT _____________________ | |

IF YOU HAVE EVER HAD A HOME SLEEP STUDY PLEASE LIST WHERE AND BY W

HO___________________________ When __________

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|Nations Sleep Disorders Center | |

|of Middle Georgia LLC. | |

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|DO YOU SMOKE? ____ YES ____ NO |DO YOU DRINK ALCOHOL? ____ YES ____ NO |

|IF YES, HOW MUCH? # ______ PACKS PER DAY |IF YES, WHAT & HOW MUCH? |

Do you Drink Caffiene? ___________ what kind__________________ how many glasses a day_________________

What time is your last cup or glass of the day?___________________

Do you Drink water?_________________ how many glasses a Day?_____________________

REVIEW OF ILLNESSES

(Check all that apply)

|ILLNESS |YES |NO |ILLNESS |YES |NO |

|HEAD INJURY | | |GASTROESOPHAGEAL REFLUX | | |

|COMA | | |LIVER DISEASE | | |

|VISUAL DISTURBANCE | | |KIDNEY BLADDER DISEASE | | |

|SEIZURES | | |ANXIETY, DEPRESSION, OR BIPOLAR | | |

|STROKE When________________ | | |WEIGHT GAIN | | |

|HIGH BLOOD PRESSURE | | |SINUS DISEASE | | |

|HEART DISEASE | | |ALLERGIES OR CONGESTION | | |

|LUNG DISEASE | | |PALATE / SINUS SURGERY | | |

|OTHER | | |COPD | | |

Do any other members of your family have sleep problems? ( Yes ( No If “yes”, please describe:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your sleep problem interfere with your work duties/responsibilities? ( Yes ( No If “yes”, please describe:

______________________________________________________________________________________________________________________

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Does your sleep problem interfere with your social activities? ( Yes ( No If “yes”, please describe:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your sleep problem interfere with your sexual activities? ( Yes ( No If “yes”, please describe:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How many hours of sleep do you usually get per night? Average __________

Does your mind ever race with thoughts when trying to fall a sleep?___________ Are you currently stressed over anything?__________

If yes what?_____________________________________________________________________________________________________

If you wake up at night when do you usually awaken? ( Soon after falling asleep ( Middle of the night ( End of the night

| Nations Sleep Disorders Center | [pic] |

|of Middle Georgia LLC. | |

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Do you Night Eat?_______________ How many times a night do you go to the restroom? ___________ Do you take a Diuretic?__________

What do you usually do when you wake up during the night?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you usually (check all that apply):

( sleep with someone else in your bed ( sleep with someone else in your room ( provide assistance to someone else at night ( sleep with the television on (Do you ever suffer from Insomnia ( Do you have Hypothyroidism ( Do you have Hyperthyroidism

Is your sleep often disturbed by (check all that apply):

( Heat ( Cold ( Noise ( Light ( Bed partner ( Not being in your usual bed ( Other __________________________

Are your sleep habits on the weekends different from the rest of the week? ( No ( Yes. If yes, please explain:

______________________________________________________________________________________________________________________

DME COMPANY I PERSONNALLY CHOOSE TO USE: ____________________________________

( I DO NOT PERSONALLY HAVE A PREFERENCE AND NATIONS SDC CAN CHOOSE FOR ME

Signature_____________________________________________________________

Date:_____________________________

| Nations Sleep Disorders Center |[pic] |

|of Middle Georgia LLC. | |

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Insurance and Financial Policy

__________(Initial) Understanding your insurance coverage can be quite challenging. Our goal is to assist you in maximizing your benefits. Each insurance plan is slightly different in its coverage services. We encourage you to become familiar with your policy exclusions, deductibles, and required co-payments. You are responsible for your deductible and required co-payments.

We will bill your insurance company for office visit appointments, follow up visits DME supplies and sleep studies. However, your co-payment for these visits and supplies is required at the time of service. If you have an unmet deductible your insurance company may apply the allowed office visit charge towards your deductible. We will then bill you for this amount. I understand the above and will pay may balance as it comes due. I understand Nations Sleep Disorders Center of Middle Georgia LLC. Does not extend credit and this may be turned over to an out sourced Collections agency if not paid in full at time of service. .

Nations Sleep Disorders Center of Middle Georgia LLC.

__________(Initial) If you are diagnosed with a sleep disorder requiring treatment with a positive airway pressure device (CPAP or BIPAP), or Oral Appliance, for your convenience Nations Sleep Disorders Center of Middle Georgia LLC., can provide the necessary equipment and supplies for you, pending Insurance authorization and contractual agreement. Additionally Nations Sleep Disorders Center of Middle Georgia LLC.. .offers on-going education, follow-up, maintenance, supplies and therapy changes & adjustments.

Freedom of Choice / Disclosure of Ownership

__________(Initial) Oral Appliances, CPAP and BIPAP equipment is also available through other medical equipment suppliers. You may choose to purchase your equipment from another provider. If you do, this will in no way affect or compromise the medical care you will receive from Nations Sleep Disorders Center of Middle Georgia LLC.. If you choose another equipment provider we will still, follow up with you in our office on regular scheduled visits. Not all suppliers offer these important services and we want our patients to receive the very best medical care possible.

Payment Methods

__________(Initial) While there are differences between insurance companies and even between insurance plans within the same company, generally most companies reimburse for a CPAP machine in one of three ways: (1) monthly rental of the machine for 6 months followed by paying the balance of the purchase price, (2) monthly rental for 10-18 months after which the CPAP machine is considered purchased, or (3) full purchase of the machine. Supplies and accessories (humidifier, mask, tubing, and filters) are always considered purchased items. During any of these methods while the insurance company reimburses us for their portion of the charges, you will also be responsible for the co-pay portion of these charges. (This will be billed even though you are not presently in the office). All Oral Appliances are purchased and not rented. We will bill you on a monthly basis for your co-pay and co-insurance. If all or any portion of your insurance deductible has not been met at the time of service your insurance company will deduct this amount from the charges you incur for CPAP equipment and supplies. We will verify this information with your insurance company. You are responsible for this amount. We will bill your Primary care insurance for you 1 time and if you have a secondary or Tertiary insurance we will only file it 1 time, as a courtesy then it is the patient’s responsibility to follow up with their Insurance company to have their claim paid. I Understand I am responsible for the $75 a month rental that my insurance does not pay till the machine is paid off.

Missed Appointments

_________(Initial) We do charge a fee for missed or reschedule appointments. If you do not keep your scheduled appointment and do not call to cancel or re-schedule your appointment at least 72 hours in advance, a missed appointment charge will be billed to you. Insurance companies generally do not cover these fees ) If a bill has not been paid on in 90days we do turn it over to a collection company. Checks, Cash, Master Card and Visa are accepted. You may contact our office to set up payment plans.

Financial Responsibility

_________(Initial) By signing below I am indicating that I understand the above insurance and financial policy information and agree to be personally responsible for my co-insurance and any portion of my deductible that has not been met at the time of service for physician office visits and or the rental or purchase of medical equipment, accessories and supplies. I also understand and agree that I am fully responsible for any charges that my insurance company does not pay for any reason, that I am solely responsible for my bill or if the checks are paid to me and should have been paid to Nations Sleep Disorders Center of Middle Georgia LLC.. If, for any reason, I default on incurred charges, I will be responsible for any reasonable attorney or collection fees incurred in the collection of these charges.

I have read and understand the above financial policy:

_______________________________________ / _____________

Signature of Patient/Responsible Party Date

| Nations Sleep Disorders Center | [pic] |

|of Middle Georgia LLC. | |

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Express Consent for Communication:

_________( Initial) By signing this form, I expressly consent to and authorize Nations Sleep Disorders Center of Middle Georgia LLC.., its affiliates and agents, including but not limited to collections agencies, debt collectors hired by them to communicate with me for any reason related to services provided by Nations Sleep Disorders Center of Middle Georgia LLC. Including collections of amounts owed for said services, this communication may be by automatic telephone system and artificial or prerecorded voices at the telephone numbers I provided to Nations Sleep Disorders Center of Middle Georgia LLC..and its affiliates and agents and also any telephone number assigned to a cellular telephone service or any service for which I am charged for the call. In addition, I further expressly consent and authorize Nations Sleep Disorders Center of Middle Georgia LLC. .and its affiliates and agents including any collection agency or debt collector hired by them to communicate with me at any phone number or email address or unique electronic identifier or mode that provide to Nations Sleep Disorders Center of Middle Georgia LLC.. Or its affiliates or agents at any time or any phone number or any email address or any other unique electronic identifier or mode Nations Sleep Disorders Center of Middle Georgia LLC.. Or its affiliates or agents find or obtain on its own which is not provided by me.

_____________________________________ _____________________________

Signature/ This Must be Signed Date

| Nations Sleep Disorders Center | [pic] |

|of Middle Georgia LLC. | |

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Instructions: Fill in your name, today’s date & your date

of birth. Answer all questions as accurately as possible.

Name_______________________________________ Date______________DOB______________

Are you currently on CPAP/BiPAP? ___ Yes ___ No, If yes, what is your CPAP/BiPAP

How likely are you to doze off or fall asleep in the following situations, in contrast to just “feeling tired”? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to think about how they would affect you.

PLEASE COMPLETE THIS BASED ON HOW YOU CURRENTLY FEEL, NOT ON HOW YOU’VE FELT IN THE PAST OR HOW

YOU WOULD FEEL WITHOUT TAKING YOUR MEDICINE OR USING YOUR CPAP.

USE THE FOLLOWING SCALE TO CHOOSE THE MOST APPROPRIATE NUMBER FOR EACH SITUATION

Epworth Sleepiness Scale

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

Situation Chance of Dozing

1. Sitting and reading…………………………………………………………. ________

2. Watching TV……………………………………………………………….. ________

3. Sitting inactive in a public place (theater, meeting, etc.)……………….. ________

4. As a passenger in a car for an hour without a break……………………. ________

5. Lying down to rest in the afternoon……………………………………….. ________

6. Sitting and talking to someone…………………………………………….. ________

7. Sitting quietly after lunch without alcohol…………………………………. ________

8. In a car, while stopped for a few minutes in traffic……………………… ________

TOTAL SCORE…………………. ________

| Nations Sleep Disorders Center | [pic] |

|of Middle Georgia LLC. | |

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Functional Outcomes of Sleep Questionnaire

Patient ___________________________________ Date of Birth _________ Date of Survey _________

FOSQ is a “quality of life” questionnaire designed specifically for people with sleep disorders. The results allow health care professionals to see how therapy has improved the quality of your life. By completing the questionnaire periodically, you can provide valuable information about the effectiveness of your treatment.

In this questionnaire, when the words “sleepy” or “tired” are used, it describes the feeling that you can’t keep your eyes open, your head is droopy, that you want to nod off or that you feel the urge to take a nap. These words do not refer to the tired or fatigued feeling you may have after you have exercised. Please answer the questions below using numbers 0 to 4. See the answer key below.

|Answer Key |

|0 = I don’t do this activity for other reasons |

|1 = Yes, extreme |

|2 = Yes, moderate |

|3 = Yes, a little |

|4 = No |

Question 0 1 2 3 4

|1. Do you generally have difficulty concentrating on the things you do because you are sleepy or tired?| | | | | |

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|2. Do you generally have difficulty remembering things because you are sleepy or tired? | | | | | |

|3. Do you have difficulty operating a motor vehicle for short distances (less than 100 miles) because | | | | | |

|you become sleepy or tired? | | | | | |

|4. Do you have difficulty operating a motor vehicle for long distances (greater than 100 miles) because| | | | | |

|you become sleepy or tired? | | | | | |

|5. Do you have difficulty visiting with your family or friends in their home because you become sleepy | | | | | |

|or tired? | | | | | |

|6. Has your relationship with family, friends, or work colleagues been affected because you are sleepy | | | | | |

|or tired? | | | | | |

|7. Do you have difficulty watching a movie or videotape because you become sleepy or tired? | | | | | |

|8. Do you have difficulty being as active as you want to be in the evening because you are sleepy or | | | | | |

|tired? | | | | | |

|9. Do you have difficulty being as active as you want to be in the morning because you are sleepy or | | | | | |

|tired? | | | | | |

| | | | | | |

|10. Has your desire for intimacy or sex been affected because you are sleepy or tired? | | | | | |

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|The information on these pages |Signed |Date |

|are complete and accurate | | |

| Nations Sleep Disorders Center | [pic] |

|Of Middle Georgia LLC | |

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Patient Rights and Responsibilities

As a patient Nations Sleep Disorders Center of Middle Georgia LLC. You have the right to: To exercise your rights as a client or to have your authorized, designated representative exercise your rights as a client.

1. _________(Initial) To select those who provide you with home medical equipment and to receive services promptly and professionally.

2. _________(Initial) To receive appropriate care and services in a professional manner without discrimination relative to your age, sex, race, religion, ethnic origin, sexual preference, physical or mental handicap, or personal cultural and ethnic preferences and to be free from any mental abuse, physical abuse, neglect, or exploitation of any kind by agency staff.

3. _________(Initial) To be informed verbally upon request and in writing of billing and reimbursement methodologies prior to the start of care and as changes occur, including fees for services and products provided, direct pay responsibilities, and notification of insurance coverage. I understand it is also my duty to inform Nations Sleep Disorders Center of Middle Georgia LLC. Of Insurance plan changes, address Changes, Telephone Changes and Primary and Specialist Physician Changes

4. _________(Initial) To participate in the development and modification of your care and service plan; to refuse treatment, within the boundaries set by law.

5. _________(Initial) To review the Nations Sleep Disorders Center of Middle Georgia LLC...Privacy Notice.

6. _________(Initial) To express concerns or grievances or recommend modification to your services without fear of discrimination or reprisal and to be involved, as appropriate, in discussions and resolutions of conflicts and/or ethical issues related to your care.

7. _________(Initial) To provide legitimate identification to Nations Sleep Disorders Center of Middle Georgia LLC.

8. _________(Initial) To not receive any experimental treatment without your specific agreement and full understanding of information explained.

9. _________(Initial) To be fully informed of your rights and responsibilities.

10. _________(Initial) I understand it can take up to 8 weeks for the complete process of my study.

11. _________(Initial) I understand a copy is sent to my referring physician only

12. _________(Initial) To provide complete and accurate information concerning your present health, medication, allergies, etc. when appropriate to your care/service.

13. _________(Initial) To involve you, as needed and as able, in developing, carrying out, and modifying your care plan, such as properly cleaning and storing your equipment and supplies, and following physician’s orders.

14. _________(Initial) To review Nations Sleep Disorders Center of Middle Georgia LLC. Safety materials and actively participate in maintaining a safe environment in your home.

15. _________(Initial) To request additional assistance or information on any phase of your health care plan you do not fully understand.

16. _________(Initial) To notify your attending physician when you feel ill, or encounter any unusual physical or mental stress or sensations.

17. _________(Initial) To notify Nations Sleep Disorders Center of Middle Georgia LLC. When you will not be able to come to a scheduled appointment.

18. _________(Initial) To notify Nations Sleep Disorders Center of Middle Georgia LLC. Prior to changing your place of residence or telephone number.

19. _________(Initial) To notify Nations Sleep Disorders Center of Middle Georgia LLC. When encountering any problem with your equipment or service.

20. _________(Initial) To notify Nations Sleep Disorders Center of Middle Georgia LLC. If you are to be hospitalized or if your physician modifies or discontinues your prescription for durable medical equipment.

Remember we are here to help you, but you have to meet us half way

| Nations Sleep Disorders Center | [pic] |

|of Middle Georgia LLC. | |

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NAME: __________________________________ TODAY’S DATE:____________ AGE: _______ DOB: _____________

Please list all of your current medications, strength, dosage, and date prescribed in the table below. Thank you.

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| Nations Sleep Disorders Center | [pic] |

|of Middle Georgia LLC. | |

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NAME: __________________________________ TODAY’S DATE:____________ AGE: _______ DOB: _____________

Please list all of your Physicians. Thank you.

| | | |Still actively seeing ? |

|List of Physicians that you see |Specialty |Last time seen | |

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TRICARE noncovered services waiver

Date: ___________________________________

Sponsor name: _____________________________________________ Sponsor ID: _____________________________

Patient name: ______________________________________________ Patient ID: ______________________________

Excluded or excludable service request and agreement

Procedure: ________________________________________________________________________________________ Approximate cost: _______________________

Diagnosis: ___________________________________________________________________________________

Date of service: _________________________

Provider name: _____________________________________________ TIN: ___________________________________

Address: __________________________________________________________________________________________

Physician signature: ________________________________________________________________________________

I hereby affirm that I have been informed and I understand that these services are excluded or excludable under the TRICARE program and therefore all costs associated with these

services are not an allowable expense under the TRICARE program. By signing the TRICARE noncovered services waiver, I am hereby agreeing in advance, in writing, to accept full

financial responsibility for all costs associated with the noncovered medical services, described in this document and performed by the named TRICARE Network Provider.

Patient signature: ____________________________________________________ Date: _____________

Beneficiary’s or legal guardian’s signature: ___________________________________ Date: _____________

Witness signature: ______________________________________________________ Date: _____________

TRICARE Operations Maual 6010.56-M, February 2008, chapter 5, section 1

2.5.1. A network provider may not require payment from the beneficiary for any excluded or excludable services that the beneficiary received

from the network provider (i.e. the beneficiary will be held harmless) except as follows:

• If the beneficiary did not inform the provider that he or she was a TRICARE beneficiary, the provider may bill the beneficiary for services provided.

• If the beneficiary was informed that the services were excluded or excludable and he/she agreed in advance in writing to pay for the

services, the provider may bill the beneficiary. An agreement to pay must be evidenced by the written consent of the beneficiary to pay

for the excluded services. General release of responsibility to pay, such as those signed by the beneficiary at the time of admission, are not

evidence that the beneficiary knew specific services were excluded or excludable.

• If the beneficiary has been notified, in writing, that the service would not be covered for any reason.

For a list of excluded or excludable services refer to:

TRICARE Policy Manual 6010.57-M, February 2008

Issue date: June 1, 1999 authority: 32 CFR 199.4(g)

TRICARE is a Department of Defense program administered by Humana Military



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****Important Notice to Patients****

Insurance Guidelines for Payment of CPAP and CPAP Supplies

The purpose of this letter is to make sure our patients are aware of the standard insurance guidelines for

payment of CPAP and CPAP replacement supplies (mask,tubing,etc.). Insurance requires that patients

come in for a periodic follow up visit in order for us to document CPAP compliance before they will

approve payment for replacement supplies (mask,tubing,etc.) as well as payment for the CPAP machine

itself. This applies to all patients, whether you are set up with your machine by an outside DME

company or by us. Below is an explanation of standard insurance guidelines for both Replacement

Supplies and for the Purchase or Return of the CPAP machine itself.

■ Replacement Supplies: Insurance requires that you come in for periodic face to face visits in

order for us to document that you are compliant in use of your CPAP machine before they will

approve payment for new supplies for you. In order to be compliant:

■ CPAP machine must be used for AT LEAST 70% of nights within each 30 day period

■ CPAP machine MUST be used > 4 hours each night (preferably 6 hours per night)

■ Face to Face visits to document compliance and to resolve any issues you may be having.

° Once per month for the first 3 months after initial set up

° Then, every 3 months for Medicare patients, every 6 months for most private

insurance,though this may vary per your specific insurance company.

____(initial) If you must return your CPAP machine for any reason (noncompliance, no longer needed,

not covered) there is a Return/Restocking fee of $100 not payable by insurance.

****Important Notice to Patients****

Insurance Guidelines for Payment of CPAP and CPAP Supplies

IMPORTANT: If we are unable to obtain the required compliance documentation to submit to your

insurance company due to missed appointments, or refusal to come in for appointments, we are left with

no choice but to bill you directly for each month rental not paid by insurance due to no compliance

documentation.

***** If your insurance changes, PLEASE NOTIFY US IMMEDIATELY, please do not wait until

you come in for an office visit. In case of CPAP rentals/supplies, we will need to reauthorize your

equipment with your new insurance company*****

Please sign and initial to verify that you have read and understand the above information. If you have any

questions or concerns, please call us and we will be glad to discuss them with you.

Thank you for your cooperation.

Patient Signature: ____________________________________________

Date: ______________________________________

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|Nations Sleep Disorders Center |-ABCD”•–—˜™Ñ |

|of Middle Georgia LLC. | |

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|Nations Sleep Disorders Center | |

|of Middle Georgia LLC. | |

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PATIENT INFORMATION

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